The Importance of Trauma-Informed Care (With Dr. Candace Burton)

Joe Gaccione 0:01
Welcome to Vital Views, podcast for UNLV School of Nursing. I'm Joe Gaccione, communications director for the School of Nursing. We are pleased to be joined by Dr. Candace Burton, director of doctoral programs at UNLV Nursing. She's also a tenured associate professor. Dr. Burton's research revolves around forensic nursing, specifically trauma-informed care and intimate partner violence. She has also explored the trauma of COVID-19 on nurses, and stress and trauma on vulnerable populations. Dr. Burton, thanks for coming in.

Candace Burton 0:28
Thanks so much. It's great to be here.

Joe Gaccione 0:29
Your director position is fairly new. Previously, UNLV Nursing had separate directors for the Ph.D. program and the Doctor of Nursing Practice program. Although there's overlap, each program is different. They're unique enough to be separate. What are your goals in overseeing both? What would you like to see differently?

Candace Burton 0:47
That's a great question. You know, they are very different. And we have not had the DNP very long. It's the terminal degree, the terminal practice degree for nurses, Doctor of Nursing Practice. And so they are, in some ways, very different, but they also have enough overlap that I think the two, the two degrees can be very helpful to each other. So, Ph.D.s typically do research, DNPs typically do more practice-oriented stuff, but someone has to translate the research into practice. So, there's an overlap there between the two, and I think it's really important for people to understand that those two disciplines can work together very closely. And with a doctoral degree in practice, DNPs have that ability to act as that translation agent for the research. So, for PhDs to still have an understanding of what's going on in the practice room, and for the DNPs to be able to look at the research done by the PhDs and say, “Hey, I know what to do with this,” that's kind of where I think we need to focus our efforts in bringing, sort of bridging that gap between the two. There's been a long history of division between research and practice in nursing, and I think having those two programs working together is where we need to focus our efforts to bridge that gap

Joe Gaccione 1:58
It’s just a thing of each side saying to the other that their role is, for lack of a better term, more important or more impactful in the nursing world? Is that it or is it different?

Candace Burton 2:09
I think it's different, I don't think it's, I don't think it's that one is more important than the other. I think it's that neither one understands what the other one is doing, necessarily. So, DNPs are not necessarily trained as researchers, they're trained to analyze and apply research, whereas PhDs are trained to design and carry out the research. So, a lot of times, researchers end up disconnected from practice, and there's no way to implement something if you don't know what the implications are for the practice environment, right? So, as a researcher, having somebody with a doctoral degree to whom you can go as a partner and say, “Hey, I just figured this out, I discovered that this is a thing. What can we do with that to improve patient outcomes?”

Joe Gaccione 2:50
They have to go hand in hand, you can't have one without the other.

Candace Burton 2:53
I think it's best that they don't, you know, exist in a vacuum from each other. I think that there's, you know, there's been a lot of confusion for a lot of years about, “What does a doctorally prepared nurse do?” and “What does a Ph.D. nurse do?” and “What does a DNP nurse do?” and whether or not there's parity with MDs and physicians and that kind of stuff, and I don't, I'm not worried about the physicians, they have their own stuff to do, but if we can bring together our best trained folks to have the capacity to do the research and the application, then we can improve patient outcomes really quickly.

Joe Gaccione 3:28
And talking about research, let's dive into yours. As we mentioned before, background includes trauma-informed care and trauma of violence and abuse. Now, this may be a dumb question, but what's the difference between the two?

Candace Burton 3:39
So, trauma-informed care is care that attends to the fact that almost everybody has some kind of trauma in their background and whether or not that trauma is going to be affecting them in the clinical encounter. So, for example, if I am a women's health nurse practitioner, I have a good friend who is, and I go to see a patient for the first time, I would like to know if that patient has a history of sexual abuse, or sexual assault in any way, because some of what happens during a women's health checkup, pap smear, that kind of thing, can be very triggering, and I would not like to have my patient freaking out in the middle of the clinical encounter, right? So, but we don't always think to ask that, right? As nurses, as clinicians, we think, “We have a job to do,” and we're gonna go in there and do it. And sometimes we forget that in the process of doing our job, we have to interact with people. And people have, as I tell my students all the time, people are messy and amazing. And so, when someone comes in to you for the first time, knowing if they have some kind of trauma in their background changes the way you provide your care and changes the way you interact with them, so that you don't create a re-traumatizing situation or a triggering situation for them.

Joe Gaccione 4:44
It has to be tough because there's so many things that could trigger, you know, you could trigger some type of emotional feeling and it could be even the slightest thing, it could be the most innocuous thing. It almost feels like you can only plan for so much but at least you have to try, at least, to minimize it as much as possible.

Candace Burton 5:03
Well, the first step in doing that is always to ask, ask your patients, you know, “Is there anything I need to know?” you know, “Is there anyone in your life that has hurt you has caused you to feel frightened or afraid? Is there anything that I can do to make this encounter easier for you?” You know, I laughed one time, my own nurse practitioner, I walked into the exam room, I was going in for a sinus infection or something, and she had little referral cards on the counter from the local domestic violence shelter, but she didn’t ask me, and she knows me, you know, so we're friends. And I said, “You didn't screen me,” and she said, “What?” and I said, “You did not screen me for violence and abuse,” and she said, “You know, I didn't. Do I need to?” And I said, “Actually, you don't, but I really would like you to make that a habit, please, with your patients going forward.” And she went right out in the hall and got her medical assistant, brought her back in, and she pointed to the cards, and she said, “We're going to start asking every patient every time.” And I tell my students that too. Every patient, every time because the first time you ask, they may not be ready to tell you, they may not trust you yet. But if you ask them every time you see them, eventually they're going to be like, “Wait a minute, this person actually cares.” And that's what trauma-informed care is. That is giving your patient permission to tell you when something has happened to them that they may be embarrassed about, frightened of remembering, upset about, giving them, you know, it's not exactly dinner table conversation, right? We don't bring that up in casual conversation, but if you ask, then they have permission to tell you, and then it's easier for both of you.

Joe Gaccione 6:29
Well, it's also about building that trust too. I mean, essentially, you are getting personal with a stranger. As a patient, you know, you're talking to this nurse, and you don't know who this person is, but as, as a nurse, and you mentioned this before, having to talk to people, you have to have that relationship building. Do you feel like that's still, in all the years of nursing, that's still an underrated component?

Candace Burton 6:51
Huge, hugely underrated. You know, and it's interesting, because other parts of my work deal with health disparities and things like implicit bias and structural racism, and we don't always stop in our pre-licensure nursing education, or even advanced practice education, to talk with our students about what it's like to have those conversations and to confront one's own prejudices and one's own biases, and we don't give them the tools to do that and then they're confronted with a situation where they're completely uncomfortable, they're frightened, they don't know how to approach this person. They don't want to offend them. They certainly don't want to hurt them, but they also don't know what to do for them. And so, sometimes we just don't pay attention to that enough. And so, I think, yeah, that is an underrated skill, creating that trust, because particularly in the inpatient setting, nobody spends more time with that patient than the nurse.

Joe Gaccione 7:40
Your research also looks at biological factors related to IPV, intimate partner violence, specifically cytokines and breath condensate. Again, dumb question, what is, what does all that mean, for the, for the layman?

Candace Burton 7:56
Yeah, so when somebody has been traumatized, particularly in a chronic manner, such as having been through intimate partner violence, an abusive relationship, you know, an abusive family environment, something like that, then there's something that happens in the body when we encounter a stressful situation. So, if you think back to your high school biology, there's something called homeostasis, right? And that's where your body is just ticking along, everything's normal, you know, things are functioning, there's no stress, there's nothing going on extra, right? When you encounter a stressful situation, we experience something called allostasis, which is your body's stress response. So, think of like fight to flight, the HPA axis activating, stress hormones going all over the place, you know, so like, if somebody were to come in here right now and yell, “Fire!” and we all ran out the door, we would be experiencing allostasis because we would be, you know, we'd have an adrenaline rush, we go running out the door. And then, when it was all over, and there was no more fire, and we could come back in the building, we go back to homeostasis. When somebody's in a chronic stress situation like that, that allostasis never stops. It doesn't abate. So, over time, you may go, say you start out at a baseline of one, and something happens and you go up to a three, then hopefully you come back to your one, right? But over time, if you don't get that return to one, you go to three, then you go to three from five, then you go from five to seven, and you just get stuck, right? So your body is in this constant stress cycle of dumping cytokines, fight or flight hormones, all kinds of things are going nuts, things that are meant to be short-term, end up being long-term, and that causes physiological problems. It also causes problems at the cellular level. So when we look at blood, and even exhaled breath, what we're looking for is the presence of those stress hormones. And particularly what my study is looking at is in women who have been through an abusive relationship, are those things not only still present in both of those body fluids, but how far out from the relationship are they still present, right? So, how long does it take, essentially, like for the body to recover after getting out of a situation like that?

Joe Gaccione 10:04
I'm assuming though, even if they're physically distant from that incident, that person, it has to tie into the mental component, almost bringing it back to what we were just talking about with that trauma, where your body's almost like it's simulating the event again, even though you're not actually going through it. Am I understanding that right?

Candace Burton 10:22
Yeah, you're absolutely right. And that's, that's something that we talk about is that trauma is not just, trauma is not just in your head, right? It's in your body, too. And so, whether or not you are emotionally coping, you may not be physiologically coping, and vice versa, right? So, I've certainly had patients who, you know, years out, you know, fine, moved on, safe, no problems, but having chronic pain, having inflammatory problems, having migraines, having fatigue, things that are tied into that constant release of stress hormones going on in your body, when it doesn't stop, your body doesn't do what it's supposed to do, right? It doesn't go back to that “one” of homeostasis, you're kind of stuck with these chemicals going around that you don't even necessarily need, but because you haven't completely recovered from all of that, you're still stuck at that five, seven, nine level.

Joe Gaccione 11:14
When treating vulnerable populations, you talked before about implicit bias, structural racism. How can nurses best promote equity, diversity, inclusion when it comes to, specifically, healthcare? Is it largely in the actual treatment? Or are there other factors?

Candace Burton 11:31
That’s a really good question. I think the first step in any of that is knowing your own biases, doing some reflective work, and thinking about, “Okay, if I see this person, you know, pick a person on the street and look at them, what do I immediately think about them?” right? “And do I think this is a homeless person? Do I think this is a person who doesn't speak English? Do I think this person is gay, straight, black, white?” you know, what are the first impressions that you have? And then ask yourself “Why?” I mean, if it's not something that is physically apparent, like, maybe they have darker skin than you, or maybe you heard them speaking a different language, if it's not something that's readily apparent, “Okay, why, what, where did that come from?” And does that influence the interaction that you have with someone to whom you're supposed to provide care? So, I think that's the first step. Another thing that I always, my students always, after I give the lecture for the pre-licensure students about these things about vulnerable populations and implicit bias and these kinds of things, they always ask me, “Well, what do I do? How do I not screw up?” And I, and I'm usually standing at the front of the room at that point, and I say, “I'm going to show you the most powerful thing you can do in that situation,” and I sit down, and they're waiting, they're like, “Well, what are you gonna tell us?” and I'm like, “This is it.” Because now you're not standing over that person, you have leveled the playing field, you're down, just like you and I are sitting across from each other, right? Now. I can look you in the eyes, you can see me, I can see you, and I'm not standing over you about to do goodness-knows-what to you, I'm not in a position of power, I'm sitting across from you ready to engage. And that is the most powerful thing you can do, is to remove that power dynamic because particularly for someone who's sick and in a hospital bed in the inpatient setting, they may not know what's going on, people are coming in and doing things to them, even in the middle of the night, they have no idea who they are, what they're going to do, “Is it gonna hurt? Is it,” you know, “Are they going to move me somewhere? Do I have to go somewhere else?” you know? So, creating that dynamic of equity in the room can be a huge first step.

Joe Gaccione 13:32
Do you think there's also a factor of time with a patient? We talked about patient-to-nurse ratios, just like patient-to-provider ratios, it almost seems like, and it sounds like, health care providers are stretched thin as they've ever been, pre- or post-pandemic. You know, having that time just to sit down with someone and also having the time to think about these things as well, when you're in the moment versus, “I have these tasks to do,” whether they're written down or mental, and then also thinking about the next patient you have to go to, the priority may not be on these factors, on thinking, “Well, how do I, you know, how do I seem to the patient? How can I, how can I promote, you know, DEI, for instance?” Do you think, I mean, is time also a factor?

Candace Burton 14:15
Oh, yeah, time is, time is huge. And that's why I say it's important to do that inner work before you get into the clinical setting. I mean, I mean, even if you're already in practice, even if you've been in practice for however long, taking some time on your own, to think through those things to maybe educate yourself, read a book, listen to a podcast, find something, excuse me, that you can get some information from that maybe will change your thinking and just, just start to raise your own awareness a little bit of when you see those things happening, whether they're happening in front of you, whether they're happening in your memory, whether they're happening in the environment around you, you know, and to be, just to become a little bit more aware and, little by little, then you become able, it becomes part of the same thing you do all day long, you know? Every, every nurse in the world can probably walk into a room and take a set of vitals with their eyes closed, right? So, but that's because we've practiced it like hundreds of times by the time you get to the point of being in independent practice, right? And it's the same thing. So, like I said, that exercise, you look at people on the street, ask yourself, “Okay, what do I think here? And why do I think that?” And if there's something at the root of that, go learn more about it, go ask, go find, you know, go, there's Harvard, I think it's Harvard, has the implicit associations test, the IATs, that are about implicit bias, and you can take those, and you go online, and they show you a set of pictures, and you click different answers, and it comes back and tells you, you know, “You are 60% more likely to prefer people with blonde hair over people with dark hair.” I mean, it's usually not that simple, but it's usually about race or sexuality or socioeconomic status, that kind of thing, but there's lots of them, and it can be very eye-opening if you've never done anything like that before, to go in there and look at those. I think they're, they're a useful tool, they definitely don't fix the problem.

Joe Gaccione 16:02
You're not the first forensic nurse we've had on the show, but I'm curious because it is such a unique path, a unique track within the field. What drew you to forensic nursing?

Candace Burton 16:11
Oh, I wanted to be a forensic nurse as soon as I knew they existed. So, I'm a second career nurse. My first degree is actually in English and Gender Studies. And so I was very interested in the dynamics around violence against women pretty much my whole career, but even before I was a nurse. And what I thought that I was going to do, I decided to go to nursing school for a lot of reasons, but what I thought I was going to do was go to nursing school, go through an accelerated bachelor's program, go straight into a women's health NP, and go right back to working in violence against women, working with women who had been through violence and abuse. I got into my BSN program, found out what forensic nursing was, absolutely wanted to be involved in that, and you, so to be a forensic nurse, you, you have to have an RN license, so I had to get through my BSN first. Then you have to have a few years, you have to have a few hundred hours of practice as a, as an RN before you can certify as a forensic nurse. And so, I had done that, but the other thing that happened to me during my BSN was that I, in the process of exploring forensic nursing, I encountered a PhD student who was studying sexual assault in South Africa, and she had gotten a grant, and she needed a research assistant. And so, we went to South Africa and learned, and I got to learn about how sexual assault is treated in a developing country and what it's like in a country where the police force is not necessarily a municipal entity, but a private entity and so, if you can pay, then you get service and if you can't, then you don't. And it was mind blowing, and it was some of the most beautiful country I've ever seen and some of the most amazing people, but also realizing, you know, we're not doing that much better over here in the United States, in terms of treating this. And so, at that point, I wanted to do both. I wanted to be a forensic nurse, and I wanted to do research. And that kind of is how I ended up on the path that I'm on.

Joe Gaccione 18:03
Since we're talking about trauma, we're talking about trauma-informed care, what resources do you recommend out there for people that might be feeling either abused or they still feel trauma? Are there, are there national resources that you recommend? Have you been in town long enough for Las Vegas to know certain, certain resources?

Candace Burton 18:21
Locally, I'm not as familiar as I'd like to be. At the national level, there are tons of different hotlines, there's actually, there's a wonderful new hotline for folks who are persons who are transgender and are experiencing mental health problems. There are mental health hotlines, there's the National Domestic Violence Hotline, these are readily findable on your phone, on your internet and they all, what's great about most of them, if you go to them on the internet, there'll be a button on the website that says, “Get me out of here,” so if it's not safe for the person to be looking at those resources, it'll close out that browser window and erase the history so that if somebody comes along behind them and checks the browser history, they don't see that they've been searching that, which is something an abusive partner might do, is check someone's phone to make sure that they're not telling anybody what's happening or that they're not looking for help like that. And it is, it is an incredibly dangerous thing to do if you are in an abusive relationship, to seek help, because the, the abusive dynamic of power and control, that means that you are taking away control from the person who's abusing you. And so, that person is going to want to reassert that control. And so, it can be incredibly dangerous and that's why those buttons exist.

Joe Gaccione 19:28
And we will have links to these resources on the episode page when it drops. That's all the time we have. Dr. Burton, thank you so much for coming in.

Candace Burton 19:34
Thanks. It was great.

Joe Gaccione 19:36
Thanks for listening out there. Hope you have a great day.

Creators and Guests

Candace Burton
Candace Burton
Tenured Associate Professor and Director of Doctoral Programs, UNLV School of Nursing
The Importance of Trauma-Informed Care (With Dr. Candace Burton)
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